Elizabeth Hofheinz, M.P.H., M.Ed. • Sun, April 6th, 2014

Researchers at the University of Massachusetts are working on what is likely the most comprehensive effort to date to develop and implement a total joint research registry. This project—Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR)—is a national consortium of hospitals focused on studying best practices. At the helm is David Ayers, M.D., Chair of the Department of Orthopedics and Physical Rehabilitation and director of the Musculoskeletal Center of Excellence at the University of Massachusetts Medical School. Dr. Ayers tells OTW, “FORCE-TJR was initiated when we received a $12 million grant from the Agency for Healthcare Research and Quality. This research registry is more in depth than other registries, and includes a patient’s complete operative record, adverse events, and surgeon and institutional characteristics, among other variables. At this point we have collected patient reported pre-and postop outcomes from nearly 40,000 TJR patients via 130 orthopedic surgeons—and there is a waiting list of surgeons who want to join. A big differentiator is that these surgeons represent all regions of the U.S. in varied hospital and surgeon practice settings (e.g., urban/rural, low and high volume). With such immense diversity we will certainly have data that is representative of typical clinical practice—not just the experience of academic centers.”

“For the first time ever we are able to statistically identify the point at which most patients and surgeons come together to decide to proceed with a total knee or hip replacement. This is a real coup and will allow us to establish and utilize national benchmarks that patients and surgeons can use in shared decision-making. As for researchers, investigators worldwide will be able to collaborate with the registry in order to further academic-private partnerships to expand the research scope.”

James Andrews, M.D.: ‘Stem Cell Use Lags Science’

Sports medicine icon Dr. James Andrews has often been in the forefront of innovation in his specialty. Reflecting on the past and future of sports medicine, Dr. Andrews tells OTW, “The major revelation in sports medicine through the years has been the arthroscope. I was a young doctor at the time it was introduced in the U.S., and I hitched a ride with the sports medicine forefathers. For awhile now we have been looking for the next practice changing revelation in sports medicine, and the thing that we’ve been homing in on is biologics We thought it would come into its own in the first decade of the new millennium, but it lagged behind because it was difficult to research and to get it out to the public.”

“Things are on the roll now, however, and stem cell therapy is all the rage. Here at the Andrews Institute we developed our own lab so that we can do cell counts and determine what we research is the most advantageous. I do caution my colleagues, however, about the use of stem cells getting out in front of us clinically, i.e., without having enough basic science behind it. What’s happening now is that patients are clamoring for it and many doctors are just going along with their demands. This is a bit dangerous, however, because we don’t know the true indications, the contraindications, what type of cells are best utilized in xyz situation, and how often it should be used. We have an increasing number of athletes heading offshore for these surgeries and we just don’t know what they are doing.”

“The fly in the ointment is that it’s difficult to develop clinical trials because professional athletes don’t want to go into a clinical trial; they don’t want the placebo they want the real deal. We need to prove that it’s advantageous for certain situations; we need to know how many cells survive, etc. If you try to do a study and the therapy is developed as a drug and you manipulate it then it must be controlled by the FDA. Funding is an ongoing problem. Fortunately, our institute has one stem cell therapy study on retired NFL players that is fully funded by a company.”

Dual Mobility Hip Replacement Dislocation Risk “Zero”

Want to reduce wear and eliminate the risk of dislocation? Try something that the Europeans have done for many years—dual mobility hip replacement. Geoffrey H. Westrich, M.D. is Research Director of the Adult Reconstruction and Joint Replacement Service at Hospital for Special Surgery (HSS). He told OTW, “Dual mobility hip replacement was introduced to the U.S. several years ago and we have been using it at HSS with great success. With traditional hip replacement we have had to worry about dislocation, instability, impingement, and long-term wear on the plastic. With a dual mobility hip replacement, instead of the plastic liner being fixed to the cup and ball moves in that, the plastic liner is press fit onto the ball in the OR. The ball inside the liner is placed on the stem; then the hip is reduced and because the ball can’t come out of the plastic liner the risk of dislocation with this prosthesis goes down to almost zero. These hips have eliminated dislocation in primary hip replacements…and in the revision setting our dislocation rates are always higher.”

“The first study involved a number of institutions, and included almost 500 dual mobility hip replacements in primary surgery. We have yet to see any dislocations with a minimum of two year follow up. The second study involved in revisions only…over 130 cases where dual mobility was used and they only had a 3% recurrent dislocation rate.”

“The major advantage to these hips is the reduction in wear characteristics. And third generation highly crosslinked plastic tested in wear simulation studies reveals little if any wear. We also have retrieval and wear studies where we see virtually no wear with this hips out to 3 million cycles. If you look at the number one reason now for revision surgery in databases is instability. It used to be wear of the plastic and loosening but because the technology is so good now fixation is not an issue.”

Robert D. D’Ambrosia, M.D. Receives AAOS Diversity Award

Dr. Robert D’Ambrosia has been honored with the Diversity Award from the American Academy of Orthopaedic Surgeons (AAOS). This award recognizes members of the Academy who have distinguished themselves through their outstanding commitment to making orthopedics more representative of, and accessible to, diverse patient populations.

Dr. D’Ambrosia is a professor and chair of the department of orthopedics at the University of Colorado where he helped shape the School of Medicine’s Diversity Policy that increased student diversity to 30%. He embraces treating underserved patient populations to reduce the healthcare disparities they face. He also was pivotal in ensuring that the University of Colorado sports medicine faculty include female practitioners to help address the needs of female sports teams. D’Ambrosia also served as AAOS President from 1999-2000.

Dr. D’Ambrosia was formerly chair of orthopedics at Louisiana State University (LSU) for 27 years. While chair of the department, he trained and mentored more than 100 LSU graduates. His contributions to the LSU program are s

In the Crossfire this week is a very sticky topic—cementing that shoulder replacement. Says John W. Sperling “If we look over all the literature one can see that cement fixation is frankly not necessary.” Not so fast says William H. Seitz, Jr., “Cement has become the gold standard and there are new designs and new techniques and we also have new techniques for cementing as well.” It’s a lively and informative debate, for sure.